character length restricfio_.ijl"di_ted on _m'ple. !.'. ' **',. , _ [ Udt_ r_ecelvea 1. TITLE OF RESEARCH TRAINING PROPOSAL (Do not exceed 56 characters, including spaces and punctuation.) Endo.qenous neural stem cells in brain self repair following iniury 2. LEVEL OF FELLOWSHIP 3. PROGRAM ANNOUNCEMENT/REQUEST FOR APPLICATIONS Predoctoral/Postdoc PA-01-100 4a. NAME OF APPLICANT (Last, first, middle initial) 4b. E-MAIL 4c. HIGHEST DEGREE(S', Hoehn, Benjamin, D bhoehn@stanford.edu B.A. 4d. PRESENT MAILING ADDRESS (Street, city, state, zip code) 4e. PERMANENT MAILING ADDRESS (Street, city, state, zip code) Department of Neurosurgery, Department of Neurosurgery, Room P-353, MSLS Building, Room P-353, MSLS Building, 1201 Welch Road, Stanford, 1201 Welch Road, Stanford, California 94305, USA California 94305, USA 4f. OFFICE TELEPHONE NO. (Area code, 4g. HOMETELEPHONE NO. 4h. PERMANENTPHONE NO. 4i. FAX NUMBER (Area code and no. no., and ext.) 'Areacode and no.) "Areacode and no.) 650-725-3111 650-714-4776 650-714-4776 650-498-4134 U.S. CITIZEN OR U.S. NONCITIZEN NATIONAL or PERMANENT RESIDENT OF U.S. 5. TRAINING UNDER PROPOSED AWARD (See Lexicon) 6. PRIORAND/OR CURRENT NRSA SUPPORT (Individual or Institutional) DisciplineNo. CategoryName 188 Biology X--_ NO _ YES (If "Yes," refer to Item 24, Form Page 5) 7a. DATES OF PROPOSED AWARD 7b. PROPOSED AWARD DURATION 8. DEGREESOUGHTDURINGPROPOSEDAWARD From(MM/DD/YY) Through(MM/DD/YY) (inmonths) Degree ExpectedCompletionDate 09101/02 06101105 36 PhD/MD 06/01/05 .1_Zo_]K{oN] [o(o]Lji,-JI =1.J_ l/_ L,_KIsi_ili.l_l:l ii _ 9. HUMAN 9a. If"Yes," ExemptionNo. 10. VERTEBRATE 9b. Assurance of ANIMALS 10a. If"Yes," SUBJECTS o_.r Compliance No. IACUCapproval 10b. AnimalWelfare [] NO IRBApprovalDate ./_ FullIRB or D NO date AssuranceNo. Expedited- 7124197 #A3213-01 YES /_-r_ Review Ix] YES 1la. NAME OF SPONSOR (Last, first, middle initial) 11b. NAME OF PROPOSED SPONSORING INSTITUTION Steinberg, Gary, K Stanford University Telephone 650-723-5575 Address Sponsored Projects Office Fax 650-723-2815 Research Management Group E-mail Address gsteinberg@Stanford.EDU 1215 Welch Road - Modular A Stanford, CA 94305-5401 11c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT Neurosurgery 12. ENTITY IDENTIFICATION NO. 11d. MAJOR SUBDIVISION DUNS NO. (ifavailable) 1941156365A1 School of Medicine 14. NAME OF OFFICIAL INBUSINESS OFFICE 13. NAMEAND TELEPHONE NO. OF ADVISOR IFDIFFERENT FROM 1la. Michael Cowan Theo Palmer Telephone 650-725-4368 Telephone 650-723-9306 Fax 650-725-6106 Name and address of institution where research training will take place if Title Assoc. Dean for Student Servc. different from Item 11b. Address Stanford University Always M-105 Address 300 Pasteur Drive Stanford, CA 94305-5121 E-mailAddress CK.MDN@forsythe.stanford.edu 15. APPLICAN_A_N CE: Icertify that the statements herein are true,complete, and accurate to the best of my knowledge, anId..___omply with the Public Health S)grviceterms and conditions if an award is issued as a result of this application. Iam aware that any false, _ent statements or claims_iay subject me to criminal, civil, or administrative penalties. Icertify that Ihave read the National Research Service Award SeT_._surance, that I_ijf/abide by the Assurance if an award is made, and that the award will not suppo_ residency training. SIGNATUR_J(f_-_uired of_ch appl'_aJI DATE .. /,_ _-/ " Fw.,J / 7/ -/---